We are currently witnessing a seminal shift in power between the world’s countries. Pascal Lamy, former head of the World Trade Organization (WTO), recently drew attention to the fact that, as Brazil, the Russian Federation, India, China and South Africa – the so-called BRICS group of countries – gain in economic and political influence, they will no longer remain policy takers but will shape the future on their own terms.1 However, the positions that these five countries will take in future global health issues remain unclear. How closely will they align their health and foreign policies? What alliances will they seek? Will they set agendas that are different from present global health priorities? They may well want to approach global health challenges in new ways.

Many analysts want BRICS to be more active in global health. As Sridhar et al. stated, “the fact that the relatively economically stable BRICS have not stepped up their commitments to the Global Fund, the GAVI Alliance, or the World Health Organization has raised questions about their commitment to global health leadership in the long term”.2 BRICS have, however, positioned themselves on a new trajectory for development and as the Chinese foreign minister expressed “participating in world affairs on an equal footing and working actively to build international systems”.3 They have recently increased their cooperation in the fields of social development, environmental protection and health, institutionalized regular meetings of their health ministers and identified common health priorities – with the stated goal of addressing emerging health threats not only within their own populations but also on a global level.

BRICS appear to be less interested in simply providing financial contributions for development assistance than in very political and more structural bilateral and multilateral approaches to global health. They are, for example, jointly promoting access to affordable, safe and efficacious medical products of high quality through the use of the WTO’s Agreement on Trade Related Aspects of Intellectual Property Rights.4 They are also emphasizing the importance of technology transfer as a way to empower developing countries through international cooperation – and have underlined the need to establish a BRICS network of technological cooperation. While a focus on trade agreements could have a beneficial impact on the health of millions of individuals in the developing world, such agreements are vulnerable to political conflicts, international disputes and the often conflicting interests of transnational drivers such as the tobacco and food industries. It has been encouraging to observe Brazil’s leadership in the Framework Convention on Tobacco Control and the recent moves by China to increase tobacco regulation at national level.

High expectations despite some major problems

In 2011, the Director-General of the World Health Organization commented that “… BRICS represent a block of countries with a … great potential to move global public health in the right direction … towards reducing the current vast gaps in health outcomes and introducing greater fairness in the way the benefits of medical and scientific progress are distributed”.5 BRICS span several continents and important regional groupings and could, in principle, bring their health agendas to all of the high-level policy forums in which they participate, such as those of the United Nations Security Council and the Group of Twenty (G20). Of course, each BRICS country has its own foreign policy goals and astutely uses health as a “soft power” strategy. BRICS have studied the approaches used by the current key players in global health, show great interest in tripartite cooperation – e.g. between a BRICS country, a non-BRICS African country and a European or American donor – and have no interest in being only junior partners in the development of a global health agenda.

For BRICS, there is no simple correlation between wealth and health. The rapid growth of their economies has led to major problems. There has been rapid urbanization, with associated high levels of urban poverty and air pollution. The opening of markets and increasing per capita incomes have led to new lifestyles and new diets. The number of elderly people has increased while levels of fertility have fallen. Most of the world’s poor people live in BRICS or other emerging economies – even though millions of the residents of BRICS have been lifted out of poverty over the last decade. Political solutions and huge financial investments will be needed, at both national and global levels, if the general health of those who live in BRICS is to be improved. It seems likely that the national health agendas of BRICS will affect and direct the global health agenda. By 2035, 35% of the world’s population will live in China or India. WHO has acknowledged how, through domestic action on universal health coverage and other health issues, BRICS have contributed to better health globally. Brazil has long been a pioneer in expanding access to health care. The Russian Federation has embarked on a high-level commitment to fight noncommunicable diseases. In 2013, the Chinese government set itself the target of increasing the gross value of its health service sector to 1.31 trillion United States dollars (US$). In 2014, the South African government announced substantial increases to its health budget. BRICS are also addressing some of the social determinants of health. In 2011, for example, the Brazilian government launched Brasil sem Miséria (Brazil without Poverty) plan. In 2013, India launched the world’s largest food subsidy plan – a plan that will cost the government an estimated US$ 22 billion per year. Such enormous investments will have an impact on the global post-2015 health agenda.

Partners not donors

Strategically – in terms of geopolitical positioning – it continues to be of great importance for BRICS to be tightly aligned with the countries of the developing world. In this alignment, BRICS wish to be considered as partners – not donors – and adhere to the principle of non-interference. Although there is some indication that BRICS’ foreign aid has risen dramatically in recent years, none of the BRICS countries regularly provides data on its foreign aid. The level of foreign aid is also difficult to quantify because such aid is not solely financial but also includes much sharing and exchange of resources, technology and knowledge. Tripartite programmes are also becoming more common. China is presently engaged in developing a joint initiative in Africa with the Bill & Melinda Gates Foundation.

BRICS are now also establishing global and regional networks. In August 2013, China hosted a forum for health ministers entitled China–Africa Health Development – indicating China’s desire to improve health throughout Africa. Brazil has been proactive in establishing cooperation between Lusophone countries and with India and South Africa – via the India-Brazil-South Africa (IBSA) Dialogue Forum. One aim of the forum is to seek closer ties with regional leaders in the developing world. The Russian Federation has taken a lead in the fight against noncommunicable diseases, in close cooperation with its politically aligned neighbours. South Africa is part of the Oslo Ministerial Group on Foreign Policy and Global Health – a Group that strives to keep global health on the agenda of the United Nations General Assembly.

The domestic health agendas of the five BRICS countries are, in many ways, dependent on how global agendas are set in areas such as economic growth, trade, foreign investment, fighting poverty, setting up social protection and ensuring universal health coverage. Although BRICS may share many common health interests, differences in their foreign policy interests may prevent them from developing a common approach to several issues on the global health agenda. A critical issue will be trade and investment in relation to processed foods, tobacco, soft drinks and alcohol. The positions of BRICS in three areas of global health diplomacy are likely to be of particular importance: the priorities to be set for an integrated post-2015 development agenda; the promotion of a global health agenda that addresses both universal health coverage and the growing burden posed by noncommunicable diseases; and global governance for health that reaches beyond the health sector – in particular to trade, intellectual property and, increasingly, to climate change and food and water security.

Acknowledgements

I thank Miriam Faid for her contributions to earlier versions of the text.